Dr. Setthakarn Atakonpan said he saw the 41-year-old Karr four different times between March and July of this year. He said that Karr's sideburns and hair under his chin were permanently removed by lasers in "preparation for a sex change operation."

One Web site boasts the first "live sex change operation." Dr. Preecha Tiewtranon headed the surgical team who performed the live operation, because he wanted "to show the world that our standards of treatment are comparable to the international level," according to the Web site.

Tiewtranon says he's been in the business of sex reassignment surgery for 25 years, and that demand for his services has increased. He says he performs three to five sex change operations a week.

Calling Bangkok the capital of sex reassignment surgery in Thailand, even in Asia, Tiewtranon claims to have many American and European patients. "Thailand is the most popular destination for cosmetic surgery because one, it's cheap, and two, our hospitals are better than most hospitals overseas," Tiewtranon says.

Tiewtranon's clinic charges about $7,500 for a sex change operation, a bargain compared with U.S. prices, which can soar into the tens of thousands of dollars. Skyrocketing insurance and the threat of lawsuits have pushed U.S. medical costs even higher, sending Americans to Thailand where they help fuel what has become a multimillion dollar industry there.

The Pratunam Polyclinic in downtown Bangkok, which confirmed that Karr was a patient, co-sponsors a popular transsexual beauty contest. Bangkok has a reputation as a welcoming community to a large, open transgender population, so much so that foreigners in search of acceptance flock to Thailand and stay for months to prepare for the surgery.